Figure 4 Eight weeks later, T1 w post contrast www.selleckchem.com/products/U0126.html axial MR shows dilatation of the common bile duct. Figure 5 Cross sectional view showing the tumor within the duodenum (asterisk). The duodenum is surrounded by the incomplete annular pancreas (arrows). DISCUSSION Symptoms Clinical manifestation of annular pancreas can occur at any age, from neonatal period to adulthood. When the duodenal constriction is minimal or absent, annular pancreas can remain asymptomatic lifelong[24]. In infants, the common clinical symptoms are vomiting and feeding intolerance[7]. Clinical manifestation in adults can present with cramping epigastric pain, postprandial fullness, vomiting, and weight loss[10,25,26]. Association with pancreatitis, or a gastric/duodenal ulcer, can also occur[7,25].
The most frequent symptom in adult annular pancreas seems to be abdominal pain[7,10]. Most adults become symptomatic between the ages of 20 and 50[25]. The differential diagnosis includes other upper gastrointestinal pathologies, such as peptic ulcer disease, duodenal web, pancreatitis, or pancreatic carcinoma[19,27]. Obstructive jaundice is described as a rare direct result of annular pancreas, but appears in coexisting periampullary malignancies[19]. Of the above-mentioned 14 cases of carcinoma associated with annular pancreas, 10 presented obstructive jaundice. The most common symptoms of primary carcinoma of the duodenum are abdominal pain and weight loss[28]. Upon her first hospitalisation, our patient��s main symptoms were postprandial nausea and vomiting, associated with a significant weight loss.
No abdominal pain was reported. Neither pancreatitis nor obstructive jaundice was apparent. Four years prior to diagnosis, the patient had been complaining intermittent occasional mild epigastric pain. In addition, over the previous 15 years, she had reported occasional vomiting. Fifteen years had passed from first symptoms until diagnosis of annular pancreas. Upon her second hospitalisation, her only symptom was jaundice. Diagnosis/radiology Annular pancreas is diagnosed by ERCP or by CT[29]. Since MRCP has become widely used, annular pancreas can be diagnosed non-invasively[30,31]. A recent study reviewed 55 cases with annular pancreas in adults[7]. Diagnosis was made with ERCP in 47%, MSCT in 18%, with MRCP in 16%, and in 13% of the patients, diagnosis was made at the time of surgery.
We were able to make the diagnosis of annular pancreas non-invasively by abdominal MSCT (Sensation 16, Siemens Medical Solutions, Erlangen, Germany) AV-951 and MRCP using a 1.5T scanner (1.5T Symphony, Siemens Medical Solutions, Erlangen, Germany). Due to the duodenal obstruction by the pancreatic ring, ERCP was not a feasible diagnostic alternative. Upon readmission, dilatation of the common bile duct was demonstrated by MRCP. Malignancy was found during explorative laparotomy. The final diagnosis was made by the pathologist.